Training probation officers in case formulation for personality disordered offenders

BACKGROUND

The UK Strategy on Managing High Risk of Serious Harm Offenders with Severe Personality Disorder proposes an important role for offender managers in completing case formulations about such offenders. There is little evidence on whether this can be achieved.

AIM

Our primary aims were to devise, implement and evaluate training in case formulation for offender managers. A secondary aim was to assess whether the training led to changes in offender manager attitudes towards working with offenders with personality disorder.

METHOD

A 5-day training programme was delivered to 20 offender managers, whose ability to carry out case formulation was assessed before and after the training using a 10-point quality checklist. Attitudes towards personality disorder were also assessed before and after. Qualitative feedback on the training was used to provide further insight into the findings.

RESULTS

Offender managers showed a significant improvement in their ability to carry out case formulation following training, with 7 of the 10 quality domains on the quality checklist rated as at least 'satisfactory' post training. Qualitative feedback highlighted reasons for some of the shortfalls in two of the three areas that did not show improvement. Improvements were shown in attitudes towards working with offenders with personality disorder in two of three domains.

CONCLUSION

Our findings provide further evidence for the effectiveness of training offender managers in case formulation. This is encouraging in terms of extending implementation of the Offender Personality Disorder Pathway, but a full trial is indicated, partly not only because sample sizes have been small so far, but also because the participants have been enthusiastic volunteers rather than randomly selected offender managers, and there are indications from other work that we know too little about optimal extent of training and about whether its effects are sustained. Copyright © 2016 John Wiley & Sons, Ltd.

The role of national policies and mental health care systems in the development of community care and community support: an international analysis

BACKGROUND

The development of adequate community support of persons with severe mental health problems is an ongoing effort. National policies and national health and social care systems play an important role in the effectiveness of these efforts.

AIMS

To get a better understanding of the ways in which national policies and (mental) health care systems can enhance the development of community support and social inclusion for people with severe mental illness.

METHOD

A comparison was made between the experiences of 75 key persons on regional community support development regarding national policies and systems in Denmark, England and the Netherlands respectively.

RESULTS

Four themes stood out as being particularly instrumental in the development of community support: - implementation of a national policy on social inclusion, - development of a national framework of responsibilities, entitlements and services, - solid funding and social inclusion incentivizing reimbursement systems, - integrated care.

CONCLUSION

National governments do have opportunities to take or retake the lead to ensure that community support and social inclusion of persons with severe mental illness health problems are not just ideological slogans but solid policy.

Longitudinal HCR-20 scores in a high-secure psychiatric hospital

BACKGROUND

The HCR-20 is a widely used 20 item structured professional judgement aid to risk assessment and management, but longitudinal studies of its value are rare, particularly with people at high risk of reoffending.

AIMS

To investigate whether the HCR-20 discriminates between patient subgroups in one high-security hospital in England, whether scores reduce with hospital treatment and whether lower scores predict discharge.

METHODS

Repeated HCR-20 ratings were made by clinical teams across five services within the hospital, two of them (women and men with intellectual disability) national services. A database of 3337 HCR-20 ratings, from 532 patients over a period of 5 years, was examined using mixed effects models.

RESULTS

As expected, HCR-20 scores were high overall, but there were differences between services in the ratings obtained. Female patients and men with intellectual disability had the highest total score. There was a significant relationship between discharge and lower clinical risk score, but not between total and risk scale scores and discharge. There were significant changes in scores over time, although these were small and may not be clinically meaningful. Differences between services were observed, with women evidencing greater change.

CONCLUSIONS

It is unsurprising that patients in two national services (for men with intellectual disability and women) have the highest HCR-20 scores; however, the finding of relatively greater risk reduction in women needs further investigation. Although we did not find ceiling effects in this sample, the clinical value of frequently repeated HCR-20 ratings may be limited for high-risk populations where any change is likely to be slow.

Addressing the inverse care law: the role of community paediatric services

BACKGROUND

Children's health suffers disproportionately from the effects of poverty. The inverse care law states that those who need care the most are the least likely to receive it. Community paediatricians are well placed to address health inequalities in children.

AIMS

To explore, using routinely collected data, whether we address health inequalities and the inverse care law, particularly for certain conditions targeted by our specialty.

METHODS

Five years of data were analysed, during which health equity audits have led to service changes in order to tackle inequities. The data include postcodes, allowing each child to be assigned to a deprivation quintile, and a range of diagnoses, including five sentinel conditions: attention deficit hyperactivity disorder (ADHD) on medication, autistic spectrum disorder (ASD), epilepsy, cerebral palsy and Down's syndrome. This allowed analysis of the caseload by deprivation index for these conditions, comparison with the background population and exploration of time trends.

RESULTS

The number of children on the caseload and their distribution across the quintiles remained stable. The proportion of deprived children (i.e. in the lowest two quintiles) on the caseload over the last five years taken together is 56%, compared to 44% in the background population. The numbers of children with ADHD on medication has almost quadrupled in deprived quintiles and doubled in the least deprived quintile, while the numbers of children with this diagnosis in the most deprived is four times that in the least deprived. Numbers of children with ASD have also increased in each quintile. In contrast, the number of children with epilepsy and cerebral palsy did not show much variation, but those from deprived quintiles made up a greater proportion of the caseload.

CONCLUSIONS

Routine data collection demonstrates that inequalities are addressed using all four quality domains of service provision and sentinel conditions more likely to affect deprived children are targeted. We believe it is possible for all services to collect and analyse data thus with minimal effort, thereby providing a foundation from which to address the inverse care law.

Ward features and stigma experiences of mental health service users in Belgium and England: a replication study

BACKGROUND

Stigmatizing attitudes can impair the quality of life of people with mental health problems. Psychiatric hospitalization can generate stigma. Are some approaches to care less stigmatizing than others?

AIMS

This study was designed to replicate findings from Flanders, Belgium in an English context, investigating how ward size and treatment approach affected service users' expectations and experiences of stigma.

METHODS

The translated Belgian questionnaire was administered to 70 service users in 15 inpatient adult mental health settings in central England. Adjustments were made to the multivariate analysis in light of the smaller sample size, in order to replicate the original equation as closely as possible.

RESULTS

Neither ward size nor individualized care proved significant in the smaller English sample, which was subject to the risk of type II error. Across two models, self-rejection correlated with age (negatively), social rejection and stigma expectations.

CONCLUSIONS

This analysis shows that attempts to translate evidence about psychiatric inpatient services must take into account differences between the settings, populations and models of care. Expectations as well as outcomes of stigma may be relevant when assessing the impact of psychiatric hospital treatment on individual patients.

Campaign appears to influence subjective experience of stigma

BACKGROUND AND AIM

An English mental health trust implemented a strategy to dispel the stigma surrounding mental illness and service users. The purpose of this study was to evaluate its impact.

METHOD

A questionnaire was mailed to 600 service users, selected at random, to evaluate the campaign's impact. Factor analysis of 243 responses yielded three factors which could be interpreted in relation to service users' perceptions of: public attitudes towards mental illness, service users' relationships with staff and other inter-personal relationships.

RESULTS

Significant improvement was found in service users' perceptions of public attitudes towards mental illness. This can cautiously be related to the main thrust of the campaign. No change was found in the other two factors, which supports the inference that the campaign specifically influenced users' experience of public portrayals of mental illness.

CONCLUSIONS

This study indicates that certain aspects of stigma may be amenable to change through a targeted campaign. While users' experience of public attitudes may be improved, at least in the short-term, other aspects of stigma did not appear to be amenable to change through community-level interventions. Different dimensions of stigma seem to demand different approaches. The intra-psychic roots of stigma may be the hardest elements to change.